Clinical and laboratory predictors of clomiphene response**Supported in part by Grant HD 05932 from the National Institutes of Health, United States Public Health Service, Bethesda, Maryland, and by a grant from the Ford Foundation

Ovarian response to follicle-stimulating hormone in women with polycystic ovary syndrome is diminished compared to ovulatory controls

OBJECTIVE

The mechanisms underlying ovarian dysfunction in polycystic ovary syndrome (PCOS) have not been definitively established. Our objective was to perform a detailed examination of ovarian responses to recombinant follicle-stimulating hormone (rFSH) in women with PCOS and controls.

DESIGN

This prospective, crossover, dose-response study included three rFSH stimulation periods. Each stimulation period involved three consecutive, daily, subcutaneous injections of rFSH administered at a single dose. Low, medium and high rFSH doses were weight-adjusted, corresponding to 0.5, 1.1 and 2.2 IU/kg/d, respectively. Stimulation periods occurred in randomized order and were separated by 8-week washouts.

PATIENTS

Thirty participants (8 PCOS and 22 controls) were studied. PCOS was defined by oligomenorrhea and clinical or biochemical androgen excess, excluding other aetiologies of ovulatory dysfunction.

MEASUREMENTS

Blood samples were obtained for hormone measurements before and 24 h after each rFSH injection.

RESULTS

Participants with PCOS had significantly greater body mass index, antral follicle count and circulating testosterone, anti-mullerian hormone (AMH) and luteinizing hormone concentrations compared with controls participants. Baseline estradiol (E2) concentrations were similar in both groups. At the lowest dose of rFSH, PCOS participants did not demonstrate E2 increments, whereas a significant increase occurred in controls. rFSH-induced E2 production per follicle was significantly reduced in PCOS participants compared with controls at all rFSH doses. Increasing T and decreasing AMH concentrations were associated with augmented E2 production per follicle.

COONCLUSIONS

Women with PCOS exhibited diminished initial E2 responses to rFSH compared with controls. These findings suggest that the mechanism of anovulation in PCOS may involve altered ovarian response to gonadotropins.

Ovulation induction techniques in women with polycystic ovary syndrome

Anovulation is very common and has several different clinical manifestations, including amenorrhea, oligomenorrhea and abnormal uterine bleeding. Various mechanisms can cause anovulation. The clinical consequences and commonest chronic anovulatory disorder, polycystic ovary syndrome (PCOS), has a prevalence that ranges between 6 to 10% of the global population. While multiple causes can eventually result in PCOS, various methods have been described in the literature for its management, often without ascertaining the underlying cause. Ovulation Induction (OI) is a group of techniques that is used in women with PCOS who are looking to conceive and are unbale to do so with natural means. This narrative review presents a summary of the current evidence and available techniques for OI in women with PCOS, highlighting their performance and applicability.

Could Cytochrome P450 2D6, 3A4 and 3A5 Polymorphisms Explain the Variability in Clinical Response to Clomiphene Citrate of Anovulatory PCOS Women?

INTRODUCTION

Cytochrome P450 2D6, 3A4 and 3A5 are involved in the metabolism of many drugs. These enzymes have a genetic polymorphism responsible for different metabolic phenotypes. They play a role in the metabolism of clomiphene citrate (CC), which is used to induce ovulation. Response to CC treatment is variable, and no predictive factors have thus far been identified.

OBJECTIVE

To study a possible link between the cytochrome P450 2D6, 3A4 and 3A5 polymorphisms and clinical response to CC.

STUDY DESIGN

Seventy-seven women with anovulatory Polycystic Ovarian Syndrome (PCOS) treated with CC were included which determined their cytochrome P450 2D6, 3A4 and 3A5 genotypes and used the results to predict ovarian response to this drug. Predicted responses based on the cytochrome genotypes were compared with the observed clinical responses using the calculation of a weighted Kappa coefficient.

MAIN OUTCOME MEASURES

Number of dominant follicles assessed by ultrasound at the end of the follicular phase and confirmation of ovulation by blood progesterone assay in the luteal phase.

RESULTS

Concordance between the predicted and observed responses for the combination of the three cytochromes was 36.71%, with a negative Kappa coefficient (K = -0.0240), which corresponds to a major disagreement. Similarly, for predictions based on the cytochrome P450 2D6 genotype alone, only 39.24% of predictions were verified (coefficient K = -0.0609).

CONCLUSION

The genetic polymorphism of cytochromes P450 2D6, 3A4 and 3A5 does not appear to influence clinical response to CC used to induce ovulation in anovulatory PCOS women.

Feasibility of a brief, intensive weight loss intervention to improve reproductive outcomes in obese, subfertile women: a pilot study

OBJECTIVE

To evaluate the feasibility of a brief, intensive weight loss intervention (IWL) to improve reproductive outcomes in obese subfertile women.

DESIGN

Pilot study of IWL versus standard-of-care nutrition counseling (SCN).

SETTING

Single-site, academic institution.

PATIENT(S)

Obese women (body mass index, 35-45 kg/m2) with anovulatory subfertility.

INTERVENTION(S)

Women were rigorously prescreened to rule out secondary causes of subfertility. Eligible women were randomized to IWL or SCN. IWL consisted of 12 weeks of very-low-energy diet (800 kcal/day) + 4 weeks of a low-calorie conventional food-based diet (CFD) to promote 15% weight loss. SCN consisted of 16 weeks of CFD to promote ≥5% weight loss. Women were transitioned to weight maintenance diets and referred back to reproductive endocrinology for ovulation induction.

MAIN OUTCOME MEASURE(S)

Feasibility of recruitment, randomization, intervention implementation, and retention.

RESULT(S)

Thirty-nine women were screened; 25 (64%) were eligible to participate, and 14 of those eligible (56%) agreed to be randomized, seven in each group. One withdrew from the IWL group and two from the SCN group. Percent weight loss was greater in the IWL group than in the SCN group (13% ± 5% vs. 4% ± 4%). Three of six women in the IWL group conceived and delivered term pregnancies. No pregnancies occurred in the SCN group.

CONCLUSION(S)

After rigorous screening, 44% of eligible women completed the study. IWL was associated with greater percentage weight loss and improvements in insulin sensitivity.

CLINICAL TRIAL REGISTRATION

NCT01894074.

Mono-ovulation in women with polycystic ovary syndrome: a clinical review on ovulation induction

Polycystic ovary syndrome (PCOS) affects 5-10% of women of reproductive age and is the most common cause of anovulatory infertility. The treatment approaches to ovulation induction vary in efficacy, treatment duration and patient friendliness. The aim was to determine the most efficient, evidence-based method to achieve mono-ovulation in women diagnosed with PCOS. Publications in English providing information on treatment, efficacy and complication rates were included until September 2015. Systematic reviews, meta-analyses and randomized controlled trials were favoured over cohort and retrospective studies. Clomiphene citrate is recommended as primary treatment for PCOS-related infertility. It induces ovulation in three out of four patients, the risk of multiple pregnancies is modest and the treatment is simple and inexpensive. Gonadotrophins are highly efficient in a low-dose step-up regimen. Ovulation rates are improved by lifestyle interventions in overweight women. Metformin may improve the menstrual cycle within 1-3 months, but does not improve the live birth rate. Letrozole is effective for ovulation induction, but is an off-label drug in many countries. Ovulation induction in women with PCOS should be individualized with regard to weight, treatment efficacy and patient preferences with the aim of achieving mono-ovulation and subsequently the birth of a singleton baby.

Limited ability of circulating anti-Müllerian hormone to predict dominant follicular recruitment in PCOS women treated with clomiphene citrate: a comparison of two different assays

The present retrospective cohort study was conducted to investigate whether serum anti-Müllerian hormone (AMH) levels, determined by either the Immunotech (IOT) or the second generation (Gen II) assay, can predict follicular recruitment in women with polycystic ovary syndrome (PCOS) undergoing ovulation induction with clomiphene citrate (CC). Patients received 50 mg CC daily for ovulation induction followed by natural intercourse or intrauterine insemination. Overall, 84 women had their serum AMH levels tested before treatment [42 patients with Immunotech (IOT), and 42 patients with the Gen II assay]. The primary outcome was to determine dominant follicle (>10 mm) recruitment in relation to AMH levels. Thirty-three (79%) patients in the IOT and 34 (81%) patients in the Gen II assay group developed a dominant follicle within 15 days after initiation of CC. Circulating AMH levels did not differ between women with or without dominant follicular recruitment in the both groups. By using either the AMH IOT or the Gen II assay, serum AMH levels were not predictive of the development of a dominant follicle. In conclusion, serum AMH levels measured by IOT or Gen II assay, has limited value to predict PCOS patients who will develop a dominant follicle following ovulation induction with CC.

The Obesity-Fertility Protocol: a randomized controlled trial assessing clinical outcomes and costs of a transferable interdisciplinary lifestyle intervention, before and during pregnancy, in obese infertile women

BACKGROUND

Obesity in infertile women increases the costs of fertility treatments, reduces their effectiveness and increases significantly the risks of many complications of pregnancy and for the newborn. Studies suggest that even a modest loss of 5-10 % of body weight can restore ovulation. However, there are gaps in knowledge regarding the benefits and cost-effectiveness of a lifestyle modification program targeting obese infertile women and integrated into the fertility clinics. This study will evaluate clinical outcomes and costs of a transferable interdisciplinary lifestyle intervention, before and during pregnancy, in obese infertile women. We hypothesize that the intervention will: 1) improve fertility, efficacy of fertility treatments, and health of mothers and their children; and 2) reduce the cost per live birth, including costs of fertility treatments and pregnancy outcomes.

METHODS/DESIGN

Obese infertile women (age: 18-40 years; BMI ≥30 kg/m(2) or ≥27 kg/m(2) with polycystic ovary syndrome) will be randomised to either a lifestyle intervention followed by standard fertility treatments after 6 months if no conception has been achieved (intervention group) or standard fertility treatments only (control group). The intervention and/or follow-up will last for a maximum of 18 months or up to the end of pregnancy. Evaluation visits will be planned every 6 months where different outcome measures will be assessed. The primary outcome will be live-birth rates at 18 months. The secondary outcomes will be sub-divided into four categories: lifestyle and anthropometric, fertility, pregnancy complications, and neonatal outcomes. Outcomes and costs will be also compared to similar women seen in three fertility clinics across Canada. Qualitative data will also be collected from both professionals and obese infertile women.

DISCUSSION

This study will generate new knowledge about the implementation, impacts and costs of a lifestyle management program in obese infertile women. This information will be relevant for decision-makers and health care professionals, and should be generalizable to North American fertility clinics.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01483612. Registered 25 November 2011.

Use of clomiphene citrate in infertile women: a committee opinion

This committee opinion describes the use of clomiphene citrate, including indications, use, monitoring, and side effects. There is also a discussion of adjuvants and alternatives to clomiphene citrate therapy.

Long versus short course treatment with metformin and clomiphene citrate for ovulation induction in women with PCOS

BACKGROUND

Polycystic ovary syndrome (PCOS) is the most common endocrinopathy among reproductive-aged women. Apart from infertility, women with PCOS often have other endocrine disorders, including insulin resistance, hyperinsulinaemia and hyperandrogenism. Metformin,combined with clomiphene citrate (CC), has been shown to be more effective in ovulation induction when compared with clomiphene citrate alone. The optimal duration for metformin pretreatment before initiation of clomiphene citrate, however, is unknown.

OBJECTIVES

To determine the effectiveness of short-course (less than four weeks) metformin plus CC versus long-course (four weeks or more) metformin plus CC with regard to ovulation and achievement of pregnancy in infertile women with PCOS.

SEARCH METHODS

We searched the Cochrane Menstrual Disorders and Subfertility Group Trials Register, the Cochrane Central Register of Controlled Trials, MEDLINE, CINAHL, EMBASE and PsycINFO (all from inception to 1 February 2012).

SELECTION CRITERIA

Randomised controlled trials comparing short-course (less than four weeks) metformin plus CC versus long-course (four weeks or more) metformin plus CC for ovulation or achievement of pregnancy in infertile women with PCOS.

DATA COLLECTION AND ANALYSIS

No trials were found that met the selection criteria.

MAIN RESULTS

No randomised controlled trials were identified.

AUTHORS' CONCLUSIONS

There are insufficient data to determine whether short-course metformin pretreatment is as effective as the conventional long-course metformin pretreatment before initiation of clomiphene citrate for ovulation induction in infertile women with PCOS. A well-designed randomised controlled trial is needed to answer this important clinical question.

The prevalence of metabolic syndrome in clomiphene citrate resistant polycystic ovary syndrome

OBJECTIVE

To investigate the prevalence of metabolic syndrome in clomiphene citrate (CC) resistant polycystic ovary syndrome (PCOS) patients.

METHODS

58 CC resistant PCOS patients, 52 CC responders, 53 fertile PCOS and 53 age and body mass index-matched normoandrogenic ovulatory fertile women were evaluated for metabolic syndrome.

RESULTS

Metabolic syndrome prevalence was 41.4% in CC resistants, in 23.1% of CC responders, in 11.3% of PCOS fertiles and 0% of controls (p < 0.0001). Waist circumference (WC) > 88 cm was 44.8%, systolic blood pressure (BP) ≥ 130 mmHg and diastolic BP ≥85 mmHg were 27.6%, TG (triglyceride) ≥150 mg/dL was 36.2%, HDL(high density lipoprotein) < 50 mg/dL was 63.8%, fasting glucose levels ≥ 100 mg/dL was 20.7% in CC resistant PCOS women. There were positive associations between CC resistance and WC >88 cm, BP ≥ 130 ≥ 85 mmHg, TG ≥ 150 mg/dL, HDL < 50 mg/dL, fasting glucose ≥ 100 mg/dL, and presence of metabolic syndrome (p < 0.05, for all). Moreover, WC > 88 cm, and HDL < 50 mg/dL were independent variables that were associated by CC resistance by multivariate regression analysis.

CONCLUSIONS

CC resistant PCOS patients have high prevalence of metabolic syndrome. These women have an increased risk of future cardiovascular disease.

Is metformin indicated as primary ovulation induction agent in women with PCOS? A systematic review and meta-analysis

BACKGROUND

A recent meta-analysis has proven that metformin (M) is highly effective for ovulation induction in the clomiphene citrate (CC)-resistant patient. There is uncertainty whether M should be introduced as a primary ovulation induction agent in polycystic ovarian syndrome (PCOS).

METHODS

We conducted a systematic review and meta-analysis to establish if M is better when given alone or in combination with CC (CC+M) when compared with CC alone. This systematic review studied live birth delivery rate as the primary outcome.

RESULTS

We identified 14 prospective trials. Analysis of these results showed a reduction in the live birth rate in the group of patients treated only with M when compared with CC alone (OR = 0.48, 95% CI 0.31-0.73, p = 0.0006). An increase in ovulation (OR = 1.6, 95% CI 1.2-2.1, p = 0.0009) and pregnancy rate (OR = 1.3, 95% CI 1.0-1.6, p = 0.05) with CC+M when compared with CC alone was reported, but no difference was found when live birth rate was analyzed (OR = 1.1, 95% CI 0.8-1.5, p = 0.61).

CONCLUSION

CC alone is superior to M alone regarding live birth rate and ovulation. The combination (CC+M) is superior to CC alone as a primary method for ovulation induction and to achieve pregnancy in PCOS. However, when addressing live birth rate, no statistically significant difference could be demonstrated. Because of the side effects profile and contraindications of M, we believe M should not be indicated as a primary ovulation induction agent in women with PCOS.

Aromatase inhibitors for ovulation induction and ovarian stimulation

Aromatase inhibitors (AIs) were originally developed for the treatment of advanced breast cancer in postmenopausal women. Their use in reproductive medicine has been extensively studied in the past decade. We reviewed the current strategies for ovulation induction for anovulatory women, mostly women with polycystic ovarian syndrome (PCOS), and the scientific basis for use of AIs in reproductive medicine. The AI, letrozole, is effective in ovulation induction in women with PCOS resistant to clomifene citrate and ovarian stimulation for intrauterine insemination and in vitro fertilization (IVF). Letrozole is an attractive option with its oral route of administration, cost, safety profile and effectiveness in ovulation induction and ovarian stimulation. Letrozole has the potential to be the first-line treatment option for ovulation induction in PCOS women, while its use in ovarian stimulation for IVF deserves further study.

Is it safe to prescribe clomiphene citrate without ultrasound monitoring facilities?

The majority of triplet and higher order multiple pregnancies now result from ovulation induction/superovulation rather than in vitro fertilisation. However, clomiphene citrate is still widely prescribed by gynaecologists and general practitioners who do not have access to ultrasound monitoring. The objective of our study was to determine the prevalence of multifollicular development with different doses of clomiphene citrate. A retrospective review of transvaginal ultrasound monitoring of 425 cycles in 182 women receiving clomiphene citrate from January 2002 to December 2003, was studied. Three or more follicles of >or= 14 mm were identified in 58 cycles (14%). Patients received 50 mg of clomiphene citrate in 52 of these 58 cycles and 25 mg in the remaining six. One patient was noted to have developed five follicles and 10 patients developed four follicles. One patient developed six follicles, despite receiving only 25 mg clomiphene citrate daily. It was concluded that a significant number of women (14%) developed three or more follicles, despite receiving low doses of clomiphene citrate.

Polycystic Ovary Syndrome, Obesity and Reproductive Implications

Polycystic ovary syndrome (PCOS) is one of the most common causes of female infertility, affecting 5–10% of women of reproductive age. The syndrome is characterized by anovulation, hyperandrogenism and polycystic ovaries. Furthermore, PCOS is associated with insulin resistance and obesity, which is present in approximately 50% of women with PCOS. Reproductive function in women with PCOS is strongly dependent on bodyweight and metabolic status. Obesity is associated with an increased risk of infertility and may also have a negative influence on pregnancy outcome. Considering the worldwide epidemic of obesity, clinical problems relating to PCOS may worsen and increase in frequency. Lifestyle interventions resulting in weight loss comprise the most successful strategy to improve symptoms of PCOS. However, many patients fail to lose weight or may quickly regain weight. It is an important challenge to develop effective lifestyle programs and adjuvant pharmacologic treatments in order to improve reproductive and metabolic health among women with PCOS.

Phenotypic and pharmacogenetic aspects of ovulation induction in WHO II anovulatory women

Because of an enormous increase in pharmacogenetic and -genomic knowledge, an era of predicting drug response on the basis of one's genome is drawing close to reality. Anovulation is the most common cause of infertility, and outcomes of treatment are often unpredictable. This review aims to summarise in what way genetic variability might modify effects of drug-metabolising enzymes, transporters and receptors, thereby altering response to drugs used in ovulation induction.

Oral agents for ovulation induction--clomiphene citrate versus aromatase inhibitors

The purpose of this review is to compare clomiphene citrate (CC) with aromatase inhibitors (AI) as the first-line therapy for WHO Group II (eu-oestrogenic) infertility. For the past 45 years CC has been the first-line therapy, as it is a simple, cheap treatment, almost devoid of side effects, and yields ovulation in 73%, pregnancy in 36% and a singleton live birth rate of 25%. The gap between ovulation and pregnancy rates has mainly been attributed to its anti-oestrogen effects on endometrium. AI block oestrogen production, not oestrogen receptors, and would therefore be expected to produce superior conception rates and less multiple pregnancies. AI have yet to undergo further large, robust clinical trials in order to fulfill this promise as a feasible alternative to CC in this role, but some preliminary trials have shown at least equality and some superiority.

Metformin in the treatment of infertility in polycystic ovarian syndrome: an alternative perspective

This editorial discusses the recent European Society for Human Reproduction and Embryology/American Society for Reproductive Medicine recommendations on the treatment of infertility in polycystic ovarian syndrome. Evidence is provided for the use of metformin in selected patients.

Use of metformin in polycystic ovary syndrome: a meta-analysis

OBJECTIVE

To update the state of evidence on the efficacy of metformin, used either alone or in combination with clomiphene citrate in women with polycystic ovary syndrome, by examining three outcomes: ovulation, pregnancy, and live birth. Sources of heterogeneity among the published randomized controlled trials are systematically assessed.

DATA SOURCES

An electronic literature search was performed using MEDLINE, EMBASE, SCOPUS, CENTRAL, Cochrane, and U.S. Food and Drug Administration databases, restricted to studies conducted on humans and published in English.

METHODS OF STUDY SELECTION

Of the 406 potentially relevant articles identified, 17 met criteria for inclusion in the meta-analysis, rendering a total sample of 1,639 women. Study quality was examined in terms of randomization scheme, masking process, adequacy of allocation concealment, statistical power, and loss to follow-up; publication bias was also assessed. Meta-analytic procedures were used to compare metformin with placebo, and metformin plus clomiphene with clomiphene alone, for all study outcomes. Exploratory analyses were conducted to assess differences in treatment effects between clomiphene-resistant and nonresistant patients, obese and nonobese patients, and trials with long and short durations of follow-up.

TABULATION, INTEGRATION, AND RESULTS

Metformin improved the odds of ovulation in women with polycystic ovary syndrome when compared with placebo (odds ratio [OR] 2.94; 95% confidence interval [CI] 1.43-6.02; number-needed-to-treat 4.0) and appears more effective for non-clomiphene-resistant women. Metformin and clomiphene increased the likelihood of ovulation (OR 4.39; 95% CI 1.94-9.96; number-needed-to-treat 3.7) and pregnancy (OR 2.67; 95% CI 1.45-4.94; number-needed-to-treat 4.6) when compared with clomiphene alone, especially in clomiphene-resistant and obese women with polycystic ovary syndrome. These treatment effects were greater for trials with shorter follow-up.

CONCLUSION

Using all available evidence, this meta-analysis suggests that metformin increases the likelihood of ovulation and, in combination with clomiphene, increases the odds of both ovulation and pregnancy in women with polycystic ovary syndrome.

Elevated body mass index (BMI) does not adversely affect in vitro fertilization outcome in young women

OBJECTIVE

To determine if elevated body mass index in young women with normal ovarian reserve was associated with poorer ovarian response, difficulty at embryo transfer, and lower clinical pregnancy rates.

MATERIALS AND METHODS

Retrospective study of 417 first, fresh in vitro fertilization cycles performed between October 2004 and December 2006. All women were under the age of 35 and had normal cycle day 3 follicle stimulating hormone and estradiol levels. Subjects were divided into groups by BMI: <18.5, 18.5-24.9, 25-29.9, > or = 30.

RESULTS

Cancellation rates, peak estradiol levels, and mean number of oocytes retrieved were similar in all groups. There was a trend toward increasing difficulty in visualizing the air bubble at time of embryo transfer and lower implantation rates at higher body mass indices. Clinical and ongoing pregnancy rates were similar among groups.

CONCLUSION

Obesity in young women does not adversely affect clinical pregnancy rates in patients treated with in vitro fertilization.

Long versus short course treatment with Metformin and Clomiphene Citrate for ovulation induction in women with PCOS

BACKGROUND

Polycystic ovary syndrome (PCOS) is the most common endocrinopathy among reproductive-aged women. Apart from infertility, women with PCOS often have other endocrine disorders, including insulin resistance,hyperinsulinaemia and hyperandrogenism. Metformin,combined with clomiphene citrate (CC), has been shown to be more effective in ovulation induction when compared with clomiphene citrate alone. The optimal duration for metformin pretreatment before initiation of clomiphene citrate, however, is unknown.

OBJECTIVES

To determine the effectiveness of short-course (less than four weeks) metformin plus CC versus long-course (four weeks or more) metformin plus CC with regard to ovulation and achievement of pregnancy in infertile PCOS women.

SEARCH STRATEGY

We searched the Cochrane Menstrual Disorders and Subfertility Group Trials Register (December 2006), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2006, 2006 issue 4), MEDLINE (1950 to 7 January 2007), CINAHL (1982 to December 2006) and EMBASE (1980 to 7 January 2007).

SELECTION CRITERIA

Randomised controlled trials comparing short-course (less than four weeks) metformin plus CC versus long-course (four weeks or more) metformin plus CC for ovulation or achievement of pregnancy in infertile PCOS women.

DATA COLLECTION AND ANALYSIS

No trials were found that met the selection criteria.

MAIN RESULTS

No randomised controlled trials were identified.

AUTHORS' CONCLUSIONS

There are insufficient data to determine whether short-chouse metformin pretreatment is as effective as the conventional long-course metformin pretreatment before initiation of clomiphene citrate for ovulation induction in infertile PCOS patients. A well-designed randomised controlled trial is needed to answer this important clinical question.

Obesity and reproduction: impact and interventions

PURPOSE OF REVIEW

To examine the impact of obesity and potential intervention upon human reproduction in the domain of fertility, fertility treatment, pregnancy and its complications.

RECENT FINDINGS

The prevalence of obesity in women of reproductive age continues to increase, with recent recognition that visceral obesity is associated with greater metabolic disturbances and reduced fecundity, even in ovulating women. Although the efficacy of infertility treatment is reduced by obesity, this effect is not profound and indeed the argument for weight reduction in young women is better serviced by the obesity-dependent increases in perinatal and maternal risks during pregnancy and potential modification of long-term health. Although lifestyle modification alone can induce significant metabolic improvement, resumption of ovulation and reduction of perinatal risks, greater weight loss, and therefore greater potential benefit, can be achieved in combination with pharmacological agents or bariatric surgery.

SUMMARY

Obesity in women has a broad, negative impact upon human reproduction. Specific risks through pregnancy are real and may be addressed by lifestyle modification leading to weight loss and improved insulin sensitivity. Obese women undergoing fertility treatment should be advised of the increased and absolute increased risks they are undertaking, and fertility centres should adopt appropriate strategies.

Evaluation of an existing nomogram for predicting the response to clomiphene citrate

OBJECTIVE

To evaluate the ability of an existing nomogram to predict response to clomiphene citrate (CC) in infertile couples with World Health Organization group II ovulatory disorders, using the free androgen index, body mass index, and menstrual-cycle history.

DESIGN

Retrospective case-notes study.

SETTING

Reproductive medicine and fertility center at a university teaching hospital in the United Kingdom.

PATIENT(S)

One hundred four anovulatory women.

INTERVENTION(S)

One hundred four anovulatory women who had been treated with CC were studied retrospectively. Age, body mass index, free androgen index, and cycle history were used to assign a likelihood of response for each patient on the basis of a published nomogram. Predicted and observed responses were compared.

MAIN OUTCOME MEASURE(S)

Ovulation rate.

RESULT(S)

The diagnostic characteristics of the model on the basis of the optimal cutoff points were as follows: sensitivity, 96% (95% confidence interval [CI]: 90%-99%); specificity, 33% (95% CI: 18%-49%); positive predictive value, 73% (95% CI: 63%-82%); negative predictive value, 80% (95% CI: 60%-99%); likelihood ratio for ovulation, 1.34 (95% CI: 1.1-1.8); likelihood ratio for resistance, 0.13 (95% CI: 0.04-0.43); kappa, 0. 26 (95% CI: 0.09-0.44).

CONCLUSION(S)

The accurate prediction of response to CC would allow more rapid transfer of nonresponders to alternative treatments and may shorten the treatment to pregnancy interval. Although the current nomogram could identify 80% of nonresponders to CC, it was insufficiently accurate for use in the present clinical setting. Moreover, the nomogram could not identify the most appropriate dose to achieve ovulation. This nomogram should be tested on patients in other clinical settings, where it may perform better.

Adipocyte resistin mRNA levels are down-regulated by laparoscopic ovarian electrocautery in both obese and lean women with polycystic ovary syndrome

BACKGROUND

The aim of this study was to investigate serum and adipocyte mRNA expression of resistin in lean and obese women with polycystic ovary syndrome (PCOS) before and 3 months after laparoscopic ovarian electrocauterization (LOE).

METHODS

Adipose tissue obtained from 12 women with PCOS (six obese and six lean, body mass index > 27 kg m(-1) as threshold point) before and after LOE was analysed. Gene expression of resistin was measured by semi-quantitative RT-PCR. Ten lean, age-matched healthy women served as controls.

RESULTS

Both lean and obese women with PCOS had significantly higher fasting and 2 h insulin and homeostasis model insulin resistance index (HOMA(IR)) values and lower fasting glucose-to-insulin ratios (G(0)/I(0)) than did the controls. The serum levels of glucose and insulin and HOMA(IR) were significantly decreased, and the G(0)/I(0) ratio was significantly increased 3 months after LOE. No difference was found in serum resistin levels between controls and either obese or lean women with PCOS before LOE, nor between PCOS patients before and after LOE. However, resistin mRNA expression levels in both lean and obese women with PCOS before LOE were significantly higher than that in controls and were decreased significantly after LOE back to control levels.

CONCLUSION

Local resistin activity may be actively involved in the pathogenesis of PCOS. LOE reduces insulin resistance and down-regulates resistin mRNA expression in lean and obese women with PCOS.

Amelioration of insulin resistance in women with PCOS via reduced insulin receptor substrate-1 Ser312 phosphorylation following laparoscopic ovarian electrocautery

BACKGROUND

Increased Ser(312) phosphorylation of insulin receptor substrate (IRS)-1 is one possible molecular mechanism of insulin resistance in polycystic ovary syndrome (PCOS). We investigated whether laparoscopic ovarian electrocautery (LOE) improved insulin sensitivity in women with PCOS and examined the underlying molecular mechanism of LOE.

METHODS

Adipose tissue and blood samples from 12 women with PCOS before, and 3 months after, LOE were analysed.

RESULTS

Before LOE, women with PCOS were found to have significantly higher 2 h glucose, fasting and 2 h insulin levels, homeostasis model insulin resistance index and lower fasting glucose-to-insulin ratio (G(0)/I(0)) than healthy, lean, age-matched controls. Serum levels of glucose and insulin were significantly decreased, and G(0)/I(0) ratio was significantly increased 3 months after LOE. Levels of activated extracellular signal-regulated kinase 1/2 in PCOS women were higher than in controls, but were significantly decreased after LOE. Levels of insulin receptor, glucose transporter-4 and phosphatidylinositol 3-kinase were lower in PCOS patients before LOE than in controls and increased after LOE. Levels of Ser(312)-phosphorylated IRS-1 in PCOS women before LOE were higher than in controls and decreased significantly after LOE, whereas IRS-1 tyrosine phosphorylation in PCOS women before LOE was lower than in controls and increased significantly after LOE.

CONCLUSION

Over the short observation period of this study, our results demonstrated that LOE effectively ameliorated insulin resistance in women with PCOS via decreased IRS-1 Ser(312) phosphorylation.

Is the addition of metformin efficacious in the treatment of clomiphene citrate-resistant patients with polycystic ovary syndrome? A structured literature review

OBJECTIVE

The aim of this literature search is to establish if metformin is efficacious when given to clomiphene citrate (CC)-resistant polycystic ovary syndrome (PCOS) patients.

DESIGN

Medline database was searched from 1 January 1980 to 1 January 2005. Inclusion criteria were prospective randomized control trials where metformin was randomized either with placebo or CC to induce ovulation in the CC-resistant patient.

RESULT(S)

Group 1: Four trials were prospective double-blind placebo controlled. When the data of the four trials were pooled, the overall effect of the addition of metformin in the CC patient was P=.0006 with a 95% confidence interval (CI) of odds ratio (OR) 1.81-8.84. Group 2: In two trials the randomization was only prospective. When the data of these two trials were pooled, the overall effect of the addition of metformin in the CC-resistant patient was P<.0001 with a 95% CI of OR 6.24-70.27. Groups 1 and 2: The combined data show an overall effect of P<.0001 with a 95% CI of OR 3.59-12.96.

CONCLUSION(S)

The addition of metformin in the CC-resistant patient is highly effective in achieving ovulation induction.

Is metformin a primary ovulatory agent in patients with polycystic ovary syndrome?

Insulin resistance is an important pathophysiological feature of the polycystic ovary syndrome (PCOS). Insulin resistance and its compensatory hyperinsulinemia contribute to the anovulation, hyperandrogenism, infertility and early pregnancy loss suffered by women with PCOS. Current evidence supports the role of metformin in the treatment of anovulation in PCOS, both in monotherapy and concomitantly with clomiphene in clomiphene-resistant patients. In addition, novel evidence suggests that insulin sensitizers may also play a role in reducing the risk of early pregnancy loss. The insulin-sensitizing agents available commercially include metformin, rosiglitazone and pioglitazone. Compared with the thiozolidinediones, metformin is the agent that has been most frequently studied in PCOS, and has the most favorable pregnancy safety profile. In conclusion, there is strong evidence supporting the use of metformin as a primary ovulatory agent in women with PCOS.

Effects of ovarian drilling in middle Black Sea region Turkish women with polycystic ovary syndrome having normal and high body mass indices

AIM

To assess the effectiveness of laparoscopic ovarian drilling (LOD) in women with polycystic ovary syndrome (PCOS) with normal and high body mass indices (BMIs).

METHODS

We investigated the effects of LOD process on two different groups of Turkish women with normal (n = 13) and high (n = 12) body mass indices. Three-puncture laparoscopy was performed under general anesthesia. Luteinizing hormone (LH), follicle-stimulating hormone (FSH), dehydroepiandrosterone-sulfate (DHEAS) and total testosterone (total T) levels were measured one menstrual cycle before the operation (in early follicular phase defined as day 3 of the menstrual cycle) and one menstrual cycle after the operation (in early follicular phase defined as day 3 of the menstrual cycle).

RESULTS

Ovarian drilling had a positive effect on FSH increase and DHEAS, total testosterone and LH/FSH ratio decrease; but BMI levels had no effect on these hormonal changes, respectively (F = 0.343, P = 0564) (F = 0.790, P = 0383) (F = 0.083, P = 0776) and (F = 0.816, P = 0376). Ovarian drilling had a positive effect on LH decrease and BMIs were effective on this change (F = 6.946, P < 0.05). LH decrease in the group with normal BMI was significantly higher than the obese group with high BMI. Ten of 13 women with normal BMI (76.9%) and eight of 12 women with high BMI (66.6%) started to see regular menses 2 to 3 months after the procedure.

CONCLUSION

Ovarian drilling is an effective procedure on PCOS. Women with lower BMI may benefit more from the procedure.

Review article: The impact of obesity on reproduction in women with polycystic ovary syndrome

The polycystic ovary syndrome (PCOS) is one of the most common causes of infertility due to anovulation in women. The clinical features of PCOS are heterogeneous and may change throughout the lifespan, starting from adolescence to postmenopausal age. This is largely dependent on the influence of obesity and metabolic alterations, including an insulin-resistant state and the metabolic syndrome, which consistently affect most women with PCOS. Obesity does in fact have profound effects on both the pathophysiology and the clinical manifestation of PCOS, by different mechanisms leading to androgen excess and increased free androgen availability and to alterations of granulosa cell function and follicle development. Notably, simple obesity per se represents a functional hyperandrogenic state. These mechanisms involve early hormonal and metabolic factors during intrauterine life, leptin, insulin and the insulin growth factor system and, potentially, the endocannabinoid system. Compared with normal weight women with PCOS, those with obesity are characterised by a worsened hyperandrogenic and metabolic state, poorer menses and ovulatory performance and, ultimately, poorer pregnancy rates. The importance of obesity in the pathogenesis of PCOS is emphasised by the efficacy of lifestyle intervention and weight loss, not only on metabolic alterations but also on hyperandrogenism, ovulation and fertility. The increasing prevalence of obesity among adolescent and young women with PCOS may partly depend on the increasing worldwide epidemic of obesity, although this hypothesis should be supported by long-term prospective epidemiological trials. This may have great relevance in preventive medicine and offer the opportunity to expand our still limited knowledge of the genetic and environmental background favouring the development of the PCOS.

Ultra-short metformin pretreatment for clomiphene citrate-resistant polycystic ovary syndrome

OBJECTIVE

To evaluate the effect of ultra-short (12 days) metformin pretreatment in clomiphene-citrate (CC) resistant polycystic ovary syndrome (PCOS).

METHOD

Eighty women with CC-resistant PCOS were randomly allocated to metformin pretreatment or usual treatment. Forty women received 1500 mg metformin daily for 12 days, followed by clomiphene 150 mg daily for 5 days along with metformin. Forty women (control group) received the same dose of clomiphene but no metformin pretreatment.

RESULTS

In the metformin group, 17 (42.5%) women ovulated, and 6 (15%) conceived. In the control group, 5 (12.5%) women ovulated but none conceived. Compared with the control group, the metformin group had significantly higher ovulation (P = 0.03) and pregnancy rates (P = 0.026).

CONCLUSION

Twelve days of metformin pretreatment improves ovulation and pregnancy rates in women with CC-resistant PCOS.

Clomiphene citrate--end of an era? A mini-review

The purpose of this review is to examine whether the time has come to replace clomiphene citrate (CC) as the first line therapy for WHO group II (eu-oestrogenic) infertility, the majority of which is associated with polycystic ovary syndrome. CC has been the first line therapy for these cases for the last 40 years. It is a simple, cheap treatment, almost devoid of side effects which yields a single live birth rate of approximately 25% of starters. Non-response to CC and the gap between ovulation and pregnancy rates have variously been attributed to its anti-estrogen effects, and high LH and androgen concentrations. Three possible contenders for the replacement of CC as first-line treatment are scrutinized: metformin, aromatase inhibitors and low-dose FSH. Each has their advantages and disadvantages, but none of them, while showing much potential promise, has been proven, as yet, to be a feasible replacement for CC in this role. For CC, it may not yet be the end of an era but it may be the beginning of the end.

Insulin-sensitizing agents: use in pregnancy and as therapy in polycystic ovary syndrome

Treatment with insulin-sensitizing agents is a relatively recent therapeutic strategy in women with polycystic ovary syndrome (PCOS) and insulin resistance. The key areas addressed in this review include PCOS and the development of type 2 diabetes mellitus and gestational diabetes, as well as the use of insulin-sensitizing agents, particularly metformin, in the management of infertility in obese and non-obese PCOS women. Treatment with metformin in PCOS women undergoing IVF and the use of metformin during gestation will be discussed. The challenge for the health care professional should be the appropriate utilization of pharmacotherapies to improve insulin sensitivity and lower circulating insulin levels resulting in beneficial changes in PCOS phenotype. Further research into the potential role of other insulin-sensitizing agents, such as pioglitazone and rosiglitazone, in the treatment of infertile women with PCOS is needed.

High dose of phytoestrogens can reverse the antiestrogenic effects of clomiphene citrate on the endometrium in patients undergoing intrauterine insemination: a randomized trial

OBJECTIVE

To compare the effectiveness of clomiphene citrate (CC) alone or combined with phytoestrogens (PE) in ovulation induction in patients who had intrauterine insemination in a randomized, double-blind study.

METHODS

A total of 134 women aged 25-35 years, who were infertile for at least 2 years and who had oligomenorrhea or amenorrhea associated with a positive menstrual response to the intramuscular progesterone-challenge test were enrolled. They were randomly treated with CC (100 mg daily for 5 days) and CC (100 mg daily for 5 days) in combination with PE (1500 mg daily for 10 days). We estimated the difference in uterine artery pulsatily index, number of preovulatory follicles, endometrial thickness, and pregnancy rate.

RESULTS

Both treatments increased follicle-stimulating hormone, luteinizing hormone, and 17beta-estradiol plasma concentrations, but the differences were not statistically significant. However, the differences in endometrial thickness of the two groups were statistically significant. No significant differences in the pulsatility index values and in the number of preovulatory follicles were noted.

CONCLUSION

A high dose of phytoestrogens can reverse the deleterious effects of clomiphene citrate on endometrial thickness and could contribute to higher pregnancy rates.

Serum and follicular resistin levels in women with polycystic ovarian syndrome during IVF-stimulated cycles

BACKGROUND

Resistin is a hormone linking obesity and insulin resistance. The aim of this study was to compare resistin levels in serum or follicular fluid from women with polycystic ovarian syndrome (PCOS) and controls, both of whom were undergoing IVF.

METHODS

We compared serum and follicular resistin levels in 21 PCOS women and in 18 healthy, normal ovulation, age- and body mass index (BMI)-matched non-PCOS women undergoing IVF. Correlations between serum or follicular fluid resistin levels and reproductive outcome were evaluated.

RESULTS

There was no significant difference in either serum or follicular resistin levels between the control group and the PCOS group as a whole or those with insulin resistance [homeostasis model assessment of insulin resistance index applied to oral glucose tolerance test (HOMA(OGTT)) <4.7]. However, resistin levels in follicular fluid were unexpectedly significantly lower than serum levels (P<0.0001) in both the PCOS and control groups. No significant correlation was found between resistin levels and BMI, estradiol, LH, or fasting or 2 h glucose or insulin levels or between follicular resistin levels and fertilization rate, implantation rate, clinical pregnancy rate, or early miscarriage rate in PCOS.

CONCLUSION

Resistin is unlikely to be a major determining factor in the growth and maturation of oocytes during IVF-stimulated cycles in PCOS.

Body fat patterning in polycystic ovary syndrome women as a predictor of the response to clomiphene

BACKGROUND

To investigate the difference in the response to clomiphene citrate (CC) based on body fat distribution in women with polycystic ovary syndrome (PCOS).

METHODS

Ninety anovulatory PCOS women were divided into two subgroups based on treatment response: women who ovulated with CC (CC responders, n = 49) and those who did not ovulate with CC (CC nonresponders, n = 41). Baseline characteristics included age, age at menarche, height, weight and body mass index [BMI; weight/(height)2]. Percentage of body fat, body fat mass and the ratio of trunk fat to leg fat mass amount (trunk-leg fat ratio) were measured by dual-energy X-ray absorptiometry (DEXA).

RESULTS

Age, age at menarche and height did not differ between the two groups. However, trunk-leg fat ratio in CC responders (0.9 +/- 0.4) was significantly lower than that in CC nonresponders (1.3 +/- 0.4) (p < 0.001). Percentage of body fat, body fat mass and BMI were also lower in CC responders (p < 0.01). On multiple regression analysis, however, trunk-leg fat ratio proved to be a superior predictor of CC responder to percentage of body fat, BMI or body fat mass (standardized regression coefficient > or = 0.510; t-values > or = 3.432; p < 0.001).

CONCLUSIONS

Response to CC in anovulatory PCOS women differs with body fat distribution.

Insulin resistance and metformin in polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is a heterogeneous disorder with widespread systemic manifestations affecting 5-10% of women of reproductive age. The accompanying insulin resistance and hypeinsulinemia mark this syndrome as a prediabetic state, with high incidence of impaired glucose tolerance, gestational diabetes, and overt diabetes. Other metabolic and biochemical changes, such as hypertension and dyslipidemia, increase the risk of cardiovascular disease. Fertility may also be impaired due to anovulation, impaired implantation, and higher rates of spontaneous abortions. All of these effects may also be related to hyperinsulinemia. Metformin, as insulin-sensitizing drug, is being evaluated for its potential long-term disease-modifying effect, such as prevention of diabetes. Its use may also help restore spontaneous ovulation and improve menstrual cyclicity, improve the success rate of induction of ovulation with clomiphene citrate and FSH, and decrease the high rate of ovarian hyperstimulation and early pregnancy loss. Nevertheless, these new exiting potential benefits of metformin should be evaluated in large randomized controlled studies, and clinicians must counsel women appropriately before the initiation of metformin therapy.

Monitoring plasma concentrations to individualize treatment with clomiphene citrate

OBJECTIVE

Recent reports have indicated that a number of individual patient characteristics are responsible for the success or failure of clomiphene citrate treatment. However, a priori individualization of doses in different patients has not been investigated. We examined the thesis that wide variability in the metabolism of the active component (zuclomiphene) contributes to variability in response.

METHODS

The dose-response relationship of clomiphene was established from a meta-analysis of data from 13 published reports. Limited data relating plasma drug concentrations to treatment outcome were examined to determine whether insufficient systemic exposure at a fixed dosage might contribute to therapeutic failure.

RESULTS

A fixed-dosage regimen of 50 mg clomiphene per day is likely to cause ovulation in only 46% of patients; subsequent increment in dosage increases the number of responders but at the expense of considerable delay in individualization of treatment. Case reports indicated that dosage based on plasma drug concentration monitoring could improve patient management, and an algorithm is proposed to facilitate treatment.

CONCLUSIONS

Prospective studies of clomiphene citrate should be performed to confirm the hypothesis that the monitoring of plasma zuclomiphene concentrations can significantly accelerate dose individualization and improve the therapeutic outcome with this "orphan" drug.

Should insulin-sensitizing drugs be used in the treatment of polycystic ovary syndrome?

Insulin resistance is a central feature of polycystic ovary syndrome (PCOS). Hyperinsulinaemia contributes to anovulation, hyperandrogenism, infertility and early pregnancy loss in women with PCOS. Chronic hyperinsulinaemia also predisposes women with PCOS to increased risks of diabetes and cardiovascular events. Current data indicate that metformin, either as monotherapy or in combination with clomiphene in clomiphene-resistant patients, is an effective treatment for anovulation in PCOS. Initial evidence also suggests that insulin sensitizers may have a role in preventing early pregnancy loss. Of the available insulin-sensitizing agents, metformin has been the agent most frequently studied in PCOS, and has the least undesirable pregnancy safety profile. Ameliorating the metabolic syndrome associated with insulin resistance in PCOS with metformin may also prevent long-term cardiovascular and diabetes complications, pending further evidence. Based on these data, metformin should be a first-line therapy for women with PCOS.

Update: The pathogenesis and treatment of PCOS

Irregular menstrual cycles, acne, and hirsutism often cause women to present to a primary care setting. This article demonstrates how to take a careful history, perform a physical examination, and order the laboratory tests necessary to diagnose polycystic ovary syndrome (PCOS). Managing PCOS complaints and maintaining important health issues are also addressed, as well as when to refer to a specialist.